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              <h1>Further Personalise Your Cognisess Experience</h1>
              <p>Get more effective, more personalized brain training by telling us a little more about yourself.</p>
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             <h1>What are your primary training objectives? Check <input name="" type="checkbox" value="" /> all that apply.</h1>
               <div class="cognisess_box">
                <ul>
                <li><input name="" type="checkbox" value="" /> Cognitive Enhancement </li>
                <li><input name="" type="checkbox" value="" /> Preventive Cognitive Health</li>
                <li><input name="" type="checkbox" value="" /> Recovery</li>
                <li><input name="" type="checkbox" value="" /> Behavioral Training</li>
                <li><input name="" type="checkbox" value="" /> Fun</li>
               </ul>
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             <h1>What cognitive skills would you like to improve most?  Check <input name="" type="checkbox" value="" /> all that apply.</h1>
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               <ul>
                <li><input name="" type="checkbox" value="" /> Memory</li>
                <li><input name="" type="checkbox" value="" /> Attention</li>
                <li><input name="" type="checkbox" value="" /> Flexibility</li>
                <li><input name="" type="checkbox" value="" /> Processing Speed</li>
                <li><input name="" type="checkbox" value="" /> Problem Solving</li>
               </ul>
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             <div class="cognisess">
             <h1>How often do you: (select one)</h1>
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                <ul>
                 <li>
                   <div class="cognisess_box_text">&nbsp;</div>
                   <div class="cognisess_box_text1">Never</div><div class="cognisess_box_text2">Rarely</div><div class="cognisess_box_text3">Sometimes</div><div class="cognisess_box_text4">Often</div></li>
                 <li><div class="cognisess_box_text">Forget someone's name who you've met several  times before </div><div class="cognisess_box_text1"><input name="" type="checkbox" value="" /></div><div class="cognisess_box_text2"><input name="" type="checkbox" value="" /></div><div class="cognisess_box_text3"><input name="" type="checkbox" value="" /></div><div class="cognisess_box_text4"><input name="" type="checkbox" value="" /></div></li>
                 <li><div class="cognisess_box_text">Lose your keys</div><div class="cognisess_box_text1"><input name="" type="checkbox" value="" /></div><div class="cognisess_box_text2"><input name="" type="checkbox" value="" /></div><div class="cognisess_box_text3"><input name="" type="checkbox" value="" /></div><div class="cognisess_box_text4"><input name="" type="checkbox" value="" /></div></li>
                 <li><div class="cognisess_box_text">Have a word on the tip of your tongue that you can't quite say </div><div class="cognisess_box_text1"><input name="" type="checkbox" value="" /></div><div class="cognisess_box_text2"><input name="" type="checkbox" value="" /></div><div class="cognisess_box_text3"><input name="" type="checkbox" value="" /></div><div class="cognisess_box_text4"><input name="" type="checkbox" value="" /></div></li>
                 <li><div class="cognisess_box_text">Forget where you parked your car</div><div class="cognisess_box_text1"><input name="" type="checkbox" value="" /></div><div class="cognisess_box_text2"><input name="" type="checkbox" value="" /></div><div class="cognisess_box_text3"><input name="" type="checkbox" value="" /></div><div class="cognisess_box_text4"><input name="" type="checkbox" value="" /></div></li>
                </ul>
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             <div class="cognisess">
             <h1>Do you have a condition known to affect cognitive function?  Check <input name="" type="checkbox" value="" /> all that apply.</h1>
               <div class="cognisess_box">
               <ul>
                <li><input name="" type="checkbox" value="" /> None</li>
                <li><input name="" type="checkbox" value="" /> High anxiety/stress</li>
                <li><input name="" type="checkbox" value="" /> ADHD</li>
                <li><input name="" type="checkbox" value="" /> Depression</li>
                <li><input name="" type="checkbox" value="" /> PTSD or TBI</li>
                <li><input name="" type="checkbox" value="" /> MCI or Alzheimer's</li>
                <li><input name="" type="checkbox" value="" /> Drug or alcohol dependence</li>
                <li><input name="" type="checkbox" value="" /> Other</li>
               </ul>
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